Normal Menstruation

Menstruation, also called menses, is just one part of the menstrual cycle in which your body prepares for pregnancy each month. A menstrual cycle is counted from the first day of one period (the first day of bleeding) to the first day of the next period. An average cycle is 28 days, but anywhere from 21-35 days is normal.

At the beginning of your cycle, the hormones estrogen and progesterone are at very low levels. During menstruation, levels of estrogen, which is made by your ovaries, start to rise and make the lining of your uterus grow and thicken. In the meantime, an egg (ovum) in one of your ovaries starts to mature. It is encased in a sac called the Grafian follicle, which continues to produce estrogen as the egg grows.

At about day 14 of a typical 28-day cycle, the sac bursts and the egg leaves your ovary, and the egg remains near the entrance to the fallopian tube until fertilized by a male sperm, after which it begins traveling through one of the fallopian tubes to the uterus. The release of the egg from the ovary is called ovulation.

After the egg is expelled, the follicle sac (now called a corpus luteum) remains in the ovary, where it continues producing hormones, but now mainly progesterone. The rising levels of both estrogen and progesterone help build up the uterine lining to prepare for pregnancy.

The few days before, during, and after ovulation is your "fertile period"—the time when you can become pregnant. Because the length of menstrual cycles varies, you may ovulate earlier or later than day 14. It's even possible for you to ovulate while you still have your period if that month's cycle is very short or period is very long. (Stress and other things can sometimes cause a cycle to be shorter or longer.) Regardless of what day in the cycle ovulation occurs, the corpus luteum will continue producing hormones only for 14 days, unless the egg is fertilized. Sperm from a man fertilizes the egg.

The fertilized egg becomes an embryo, passes down the fallopian tube, and implants in the lining of the uterus. The growing pregnancy releases a hormone (hCG), which stimulates the corpus luteum. The corpus luteum makes all the progesterone needed to keep the egg implanted and growing until a placenta (an organ connecting the fetus to the mother) develops. The placenta then makes hormones and provides nourishment from the mother to the growing embryo.

If an egg is not fertilized, the corpus luteum stops making hormones (in 14 days) and gets reabsorbed in the ovary. Estrogen and progesterone levels drop again, the lining of the uterus breaks down, menstruation (bleeding) begins, and the cycle starts all over again.

This cycle will continue every month starting from about age 12 years old to an average age of 51 years old when menopause signals the end of menses and the ability to become pregnant.

Heavy Menstrual Bleeding

Most women lose an average of about 2 ounces (60 milliliters [ml]) of blood or less during normal menstruation. However, in some women, menstrual bleeding can be significantly heavier and/or longer. This is called menorrhagia . This happens if you lose more than 80 ml of blood and have a period lasting for more than seven days. This can be caused by a number of conditions and can lead to anemia and other complications.

Absence of Menstruation

The absence of menstruation is categorized as primary or secondary. Primary amenorrhea occurs when a girl does not start to menstruate within the normal time frame of sexual development. Primary amenorrhea is diagnosed if there is no menses by age 14 in the absence of growth or development of secondary sexual characteristics; or if there is no menses by age 16 regardless of presence of normal growth and development with the appearance of secondary sexual characteristics.

Secondary amenorrhea occurs when previously initiated menstrual periods are absent for at least three cycles (for reasons other than menopause).

Other Possible Types of Abnormal Bleeding

Light bleeding in between periods can have many causes. It can be the result of a hormonal imbalance (causing lack of ovulation), medicines (birth control pill), infections, abnormal growths on the cervix or uterus, or miscarriage .

Menometrorragia—bleeding irregularly in between periods, then bleeding heavily at expected menses

When a woman loses greater than 80 ml of blood during menses and also bleeds irregularly in between periods, it is called menometrorragia. This can be caused by a number of factors including hormone imbalances.

Hypomenorrhea—very light periods

Female athletes often have light periods and/or fewer periods due to the hormonal changes associated with extreme exercise and low body mass index. Anorexia and other conditions may also be associated with hypomenorrhea, oligomenorrhea (too few menses), or amenorrhea.

Anolulatory cycle—because ovulation does not occur, no corpus luteum is formed; the cycle may be of any length and may be unpredictable

In a normal ovulatory cycle, ovulation occurs. The cycle is regular whether or not it is the usual 28-day cycle (ovulation on day 14); or, say, a 35-day cycle (ovulation on day 21). When ovulation does not occur, the corpus luteum is not able to produce the hormones (for 14 days) that prepare the uterus and stop it from shedding. Menstrual flow can happen at any time.

Less commonly, women may ovulate, but changes in the length of the follicular phase or other conditions can cause:

Polymenorrrhea—too many menses close together (less than typical 21 days)

Oligomenorrhea—too few cycles (menses far apart)

Possible Causes of Abnormal Bleeding

There are many causes of abnormal bleeding. Examples of causes include:

Tests

Blood tests—Your doctor will measure levels of hormones and other factors in the blood, as well as to check for pregnancy.

Endometrial biopsy —A small amount of tissue is scraped from the lining of your uterus and examined under a microscope.

Ultrasound—A device that uses sound waves to create an image of your pelvic organ is placed on your abdomen or inside of your vagina.

Laparoscopy —A thin tube with a tiny camera attached is inserted through a small incision below or through your navel, allowing the doctor to look inside your abdomen.

Hysteroscopy —A thin tube with a tiny camera attached is inserted into your vagina and up through your cervix, allowing your doctor to see inside your uterus.

Amenorrhea (Lack of Menstruation)

It may be difficult for your doctor to diagnose the cause of your amenorrhea . Evaluation usually includes the following:

Initial Evaluation

You will be asked about:

Your family and medical history

Your lifestyle, eating, and exercise habits

Stress

Changes in body weight

Your menstrual periods

Birth control

Your doctor will also perform a physical exam, including a pelvic exam.

Tests

The most common cause of secondary amenorrhea is pregnancy. If your menstrual period is at least 2-3 weeks overdue and you are sexually active, the first consideration is pregnancy.

Your doctor may recommend testing your blood for hormone levels:

Androgen excess

Estrogen deficiency

Problems with the endocrine system(hormone production)

Prolactin in the blood

Thyroid hormone

Further Testing

Other tests that may be done include:

Imaging of the brain to evaluate the pituitary gland—Sometimes a small, noncancerous growth can produce excess hormones that interfere with the normal menstrual cycle.

Ultrasound scans of your abdomen and pelvis

Chromosome studies

In her own words: living with amenorrhea

As told to Mary Calvagna, MS

Karen is a 30-year-old health care professional. For close to two years, she didn't have regular periods (a condition called amenorrhea). At the same time, she was underweight, exercising a lot, and not eating enough to compensate for this exercise. Now, five years later, she's still exercising, but she's eating well and menstruating-and she is much healthier for it.

What was your first sign that something was wrong? What symptoms did you experience?

I started getting my periods much less often-every other month or every three months. They were also very light and only lasted two to three days. Then, I stopped getting my period altogether. At the same time, I lost about 20 pounds. I had just moved back home after graduating college. And while at college, my eating habits were pretty poor; I drank beer on most weekends, and didn't exercise much. So when I came back to my mom's house where I had healthy meals, very little alcohol, and more time to exercise, I quickly lost the excess weight–and then some.

What was the diagnosis experience like?

The diagnosis was pretty simple. After reviewing my menstrual history and weighing me, the nurse practitioner in my gynecologist's office asked me about my eating and exercising habits. She also did some blood tests to rule out other conditions that can cause amenorrhea. When all of those blood tests came back negative, she determined that the amenorrhea was caused by my quick weight loss.

What was your initial and then longer-term reaction to the diagnosis?

At first, I was relieved not to have to deal with my period. And since the blood tests were all negative, I didn't think it was any big deal to not have my period. But then as we discussed the effects of not having my period, I became more concerned. Since I wasn't having my period, my body wasn't producing enough estrogen, which can decrease bone density. As an athlete, this worried me. It could increase my risk of injury and hinder my performance.

How is amenorrhea treated?

In the short term, the nurse practitioner prescribed me birth control pills, which caused me to have a regular period. I also took a calcium supplement daily to help protect my bones. For the longer term, I worked on gaining weight.

After almost two years of irregular periods, no periods, and periods only while on birth control pills, I was eating better and gained enough weight so that my body would menstruate on its own. For the past five years, I have been at a healthful weight and been having regular periods.

Did you have to make any lifestyle or dietary changes in response to your condition?

I made a conscious effort to eat more and to eat a little more fat. I had gotten somewhat caught up in the "fat free" craze and was eating a lot of salad, vegetables, grilled chicken, and cereal. I wouldn't eat anything that had fat in it. I started allowing myself a little more fat and more calories to meet my energy needs. This was especially important because I was working out so much; I needed more calories than a year earlier when I wasn't exercising regularly.

Did you seek any type of emotional support?

This wasn't an emotionally stressful condition. I talked with my mom about it, and she encouraged me to gain weight. She, as well as my brothers, were concerned that I had lost 20 pounds in such a short period of time. My brothers were especially vigilant in trying to get me to eat more.

Does amenorrhea have any impact on your family?

Other than my mom and brothers worrying about me, amenorrhea really did not affect my family. If I was married and trying to start a family, that would have been a different story.

What advice would you give to anyone living with amenorrhea?

It is important to take care of amenorrhea quickly. The lack of estrogen can cause serious bone loss that you may not be able to regain. Although you may enjoy the freedom of not having a period and the physical and mental symptoms that come with it, it's really not a healthful way to be. Find the weight that is healthful for you-one that you can easily maintain with your usual eating and exercise patterns and one at which you have a regular period every month. If eating is an issue for you, ask your doctor for a referral to a registered dietitian (RD). An RD can help you develop healthful eating patterns that you are comfortable with.

Interviews were conducted in the past and may not reflect current standards and practices in medicine. Talk to your doctor to learn more about how this condition is diagnosed and managed today and what treatment approaches are right for you.

Menstrual disorders have a variety of causes, which may or may not be preventable.

For the cases that can be prevented, the following tips may help reduce your risk of developing menorrhagia or amenorrhea .

Menorrhagia or Anovulatory Bleeding

Treat Conditions That Can Lead to Heavy Bleeding

Certain conditions can often be treated before they cause heavy bleeding. Examples include:

Thyroid disorders

Blood clotting problems

Hormone imbalances

Pelvic infection

Amenorrhea

Reduce the Intensity of Your Exercise Routine

Excessive and intense exercise can cause you to stop having menstrual periods. If you exercise compulsively due to fear of gaining weight, you may have an eating disorders , such as anorexia nervosa or bulimia nervosa . It is not uncommon for women with eating disorders to exercise 2-6 hours a day. If you have an eating disorder, you need to see your doctor to get proper treatment.

On the other hand, if you exercise intensely because you are an athlete, it may be difficult for you to change your exercise routine. To prevent the complications associated with this type of amennorhea, talk to your doctor about whether you should take calcium . You may also want to consider taking birth control pills.

Maintain an Appropriate Weight and Level of Body Fat

Amenorrhea is often related to levels of body fat—either too much or too little. Your doctor can help determine your appropriate weight and body fat levels. You should not lose too much weight or lose weight too quickly. Along the same lines, you should not gain too much weight or gain too quickly. These extremes can affect your menstrual cycle.

If you need to lose weight, your doctor or a dietitian can help you make adjustments so that your diet is well-balanced and adequate in calories. If you have an intense fear of gaining weight or feel that your eating is compulsive and out of control, you should also be assessed for eating disorders.

Get Help for an Eating Disorder

Eating disorders, such as anorexia nervosa and bulimia nervosa, often lead to amenorrhea. Eating disorders are serious disturbances in eating behavior, such as extreme and unhealthy reduction of food intake or severe overeating. They are accompanied by feelings of distress or extreme concern about body shape or weight.

Anorexia nervosa is an eating disorder in which you have an obsession with dieting and exercise that leads to excessive weight loss.

Bulimia nervosa is an eating disorder in which you eat large amounts of food (binging) and then use inappropriate means (vomiting, laxatives, excessive exercise) to rid your body of the food (purging). You eat compulsively and feel unable to stop, then purge to prevent gaining weight.

If you think you may have an eating disorder, seek help from your doctor.

Reduce Your Stress Level

High levels of stress can disrupt your menstrual periods. In addition to reducing your overall stress level, you should get more rest and relaxation. You may also benefit from relaxation techniques, such as meditation , deep breathing, progressive relaxation, yoga , and biofeedback . These techniques help you pay attention to tension in your body and release it with exercises that help quiet your mind and relax your muscles. Regular enjoyable activities can also help you relieve stress.

Treat Conditions That Can Lead to Amenorrhea

Certain conditions can be treated before they lead to amenorrhea. Examples of these conditions include:

Description of Services Provided:Here you'll find articles, news releases, and fact sheets for consumers and professionals on a variety of women’s health issues, including menstrual disorders.

Last reviewed September 2012 by Brian Randall

Last updated Updated: 09/11/2012

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

A risk factor is something that increases your likelihood of getting a disease or condition.

It is possible to develop a menstrual disorder with or without the risk factors listed below. However, the more risk factors you have, the greater your likelihood of developing a menstrual disorder. If you have a number of risk factors, ask your doctor what you can do to reduce your risk.

Menorrhagia (Heavy Bleeding)

Most women experience heavy bleeding at some point during their reproductive years. Risk factors associated with menorrhagia include:

Obesity

Excess body fat is a risk factor for menorrhagia. Hormones in fat tissues can convert into estrogen. When this happens, the endometrial lining thickens causing heavier menstrual bleeding.

Conditions

You may be at increased risk for menorrhagia if you have one of the following gynecologic conditions:

Age

Young Women

The reason for these changes is due to the woman's reproductive system maturing.

Older Women

If you are approaching menopause , you may have heavier periods. Women who have menstrual periods at an older age than average may also be at risk for heavy menstrual bleeding.

Contraceptives

If you use a copper intrauterine device (IUD), you are slightly more likely to have heavy menstrual periods.On the other hand, progestin-containing IUDs (eg, Mirena ) are more likely to decrease menstrual bleeding.

In most cases, oral contraceptives decrease menstrual bleeding. If you have heavy bleeding while taking the pill, contact your doctor.

Medications

Imbalances of Hormones and Other Body Chemicals

Some women have imbalances in estrogen and progesterone that can cause them to skip menstrual periods. In this case, there may be overgrowth of the lining of the uterus (endometrium), which can lead to very heavy bleeding when menstruation returns.

Amenorrhea (Lack of Menstruation)

Risk factors for amenorrhea include:

Excessive Physical Activity

If you exercise very strenuously, you may be at risk for primary or secondary amenorrhea. Female athletes who participate in ballet, gymnastics, rowing, long-distance running, and cycling are especially at risk.

Eating Disorders

Having an eating disorder, such as anorexia nervosa or bulimia nervosa , puts you at risk for amenorrhea. This may be due to inadequate nutrition, low body fat, rapid weight loss, and hormonal and psychological factors.

Stress

You may skip menstrual periods if you are going through major life changes, or having problems with work, school, or relationships. A change in environment, such as moving, can cause you to miss periods. It appears that emotional stress prevents the brain from sending certain signals to the ovaries. Once the stressful situation has been alleviated, menses usually returns to its previous cycle.

Conditions

In most cases, amenorrhea does not indicate that you have a serious medical problem. In some cases, however, amenorrhea results from medical problems, such as:

Most women have menstrual irregularities, such as heavy bleeding and missed periods, at some point in their reproductive lives. However, you should contact your doctor if you experience the following symptoms:

Menorrhagia (Heavy Bleeding)

Women tend to overestimate how much blood they lose during their periods. The following symptoms may indicate menorrhagia :

Your pads and tampons are saturated with blood (and need to be changed) more frequently than once every hour.

Amenorrhea (Lack of Menstruation)

Primary Amenorrhea

You are 14 years old or older, have not had normal sexual development (development of breasts and/or pubic hair), and have never had a menstrual period.

You have not had a menstrual period, and it has been at least two years since you went through puberty (normal sexual development).

Secondary Amenorrhea

During early adolescence, it is common for menstrual periods to be irregular, at least for the first 18 months after the first period (menarche). It is also common for menstrual periods to be irregular as you approach menopause (usually between the ages of 40-58, sometimes slightly earlier or later). Menstrual periods also stop during pregnancy.

If you are not pregnant or entering menopause, you may have secondary amenorrhea. This may be the case if you had normal menstrual periods, but they have stopped for at least three consecutive months.

You have a unique medical history. Therefore, it is essential to talk with your doctor about your personal risk factors and/or experience with menstrual disorders. By talking openly and regularly with your doctor, you can take an active role in your care.

General Tips for Gathering Information

Here are some tips that will make it easier for you to talk to your doctor:

Bring someone else with you. It helps to have another person hear what is said and think of questions to ask.

Write out your questions ahead of time, so you do not forget them.

Write down the answers you get, and make sure you understand what you are hearing. Ask for clarification, if necessary.

Do not be afraid to ask your questions or ask where you can find more information about what you are discussing. You have a right to know.

Specific Questions to Ask Your doctor

About Menorrhagia (Heavy Bleeding)

What could be causing my heavy bleeding?

What kinds of tests should I have?

How serious is my condition?

Where can I get more information?

About Your Risk of Developing Complications of Menorrhagia

Am I at risk for anemia?

Do I need to be concerned about infertility?

How can I reduce my risk of toxic shock syndrome?

Are there any other complications I should be concerned about?

About Treatment Options for Menorrhagia

What treatments are available for heavy bleeding?

Are there medicines that can help me? If so,

What benefits can I expect?

What side effects can I expect?

Are there any surgeries that can help heavy bleeding? If so:

What benefits can I expect?

What risks may be involved?

Are there any alternative or complementary therapies that may help?

Is there anything else I can do to reduce the bleeding?

About Amenorrhea (Lack of Menstruation)

Why have I not been having menstrual periods?

What kinds of tests should I have?

How serious is my condition?

Where can I get more information?

About Your Risk of Developing Complications of Amenorrhea

Am I at risk for bone loss and osteoporosis?

Do I need to be concerned about infertility?

Are there any other complications I should be concerned about?

About Treatment Options for Amenorrhea

What treatments are available for this condition?

Are there medicines that can help me? If so:

What benefits can I expect?

What side effects can I expect?

Is there anything else I can do to make my periods regular?

Are there any alternative or complementary therapies that may help?

About Your Outlook

What are the chances of my condition improving?

What should I do if this problem returns?

About Lifestyle Changes

What lifestyle changes can I make to improve my condition?

Do I need to do anything about my diet, exercise routine, weight, stress, or other habits?

Menorrhagia (Heavy Bleeding)

The treatment options for menorrhagia are aimed at:

Eliminating the underlying cause of the heavy bleeding

Reducing the heavy bleeding with medicines, surgical procedures, or other treatments

A major goal of treatment is to prevent anemia.

Amenorrhea (Lack of Menstruation)

The treatment options for amennorhea are aimed at:

Identifying and treating underlying conditions

Restoring hormonal imbalances

Identifying lifestyle factors that may be causing the absence of a menstrual period

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY.
Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.